Sri Lanka: health as a weapon of war?BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b2304 (Published 08 June 2009) Cite this as: BMJ 2009;338:b2304
All rapid responses
I beg your kind attention to coercive population control activities at Kilinochchi (1). In addition to this selective Tamil population control activity in Kilinochchi and other places in Vanni, systematic activity adversely affecting the Tamils continues in the following ways
1. Government has stopped conducting family planning clinics at South at the request of BoduBala Sena (2). But family planning activities at North and East targeting Tamils continue. I have discussed with several Medical Officers in charge of Maternity and Child Health in the North and East and understand this is one reason why the Governor of NP want to keep unqualified RDHS's at Kilinochchi and Mullaitheevu.
2. Statistics shows clearly the Family Health Bureau based clinics target more on minorities. "Statistics in 2012 of the 4,362 sterilization surgeries conducted by the Family Health Bureau, 2,877 were conducted on Sinhala women, while 1,035 and 450 were conducted on Tamil and Muslim women respectively." (3)(compare with 2012 census population figures approximately 75% Sinhalese 15% (Tamils both) 10% Muslims) (4)
3. The regime provides Rs.100,000 incentive for the third child of armed forces which is almost 100% of Sinhalese.(5)
Unless we systematically campaign and expose this activity, soon Tamils will be gradually eliminated.
Dr Shiamala Suntharalingam
BSc (Hons), MB BS, DRCOG, DFFP, LoCIUT,LoCSDI, MRCGP, FRACGP
GP Canberra Australia
Competing interests: No competing interests
We have read with interest, the letter by Dr. Suntharalingam, entitled
“Sri Lanka: health as a weapon of war?” (BMJ 2009;338:b2304). We have
great reservations regarding the serious errors in factual content
throughout this letter, and the doubtful motives of the author. Although
we disagree with her analysis, we do not fault BMJ for publishing it as we
do believe the freedom of expression. To paraphrase Voltaire “I may not
agree with what you say, but I will defend to the death your right to say
Dr. Suntharalingam stated that she worked as a volunteer for a short
period in the North of Sri Lanka in 2003. It is important to state the
fact, at that time, this region was completely controlled by the
Liberation Tigers of Tamil Eelam (LTTE) terrorists, and only a LTTE
supporter or ardent sympathizers of them were allowed to enter this
region. It is similar to saying that she worked in Tora Bora in
Afghanistan for Al-Qaeda as a volunteer, but implying that she had nothing
to do with the dreaded group. Even though we have no problem with this,
as everyone has the freedom to choose what they want to be or do, the area
health authorities and the General medical Council in UK would be indeed
be offended by her direct connections to a banned terrorist group.
She quotes from an article by Muthukrishna Sarvananthan (a respected
Tamil individual) who wrote a report on North and East of Sri Lanka for
the US government. His writing about this area covered the period from
7CU24Q-full_report.pdf/$File/full_report.pdf).). What Dr. Suntheralignum
did not mention was that LTTE was in total control of the area during that
period, and at that time the Sri Lanka army was confined to the barracks
as per the governmental orders and ceasefire agreement. Therefore, if the
conditions were appalling, it was directly due to the dictatorial and
fanatic behaviors of the LTTE terrorist leaders. In fact this was
mentioned by Mr. Sarvananthan who further emphasized the fact that
conditions in this region were poor due to the lack of civil rights and
the brutal dictatorship prevailing under the LTTE. Some of these include
unfair taxation that was used by the LTTE's for its military purposes, and
summary killings. Indeed, many in Sri Lanka who were concerned about the
absence of accountability of the de facto LTTE rule criticized the Sri
Lanka Government for abandoning its rights and duties towards its citizens
by allowing the LTTE to be in control and causing havoc in the North and
Dr. Suntharalingam mentioned the lack of medicine and food in this
area and interestingly quotes website, “Tamil Net” as a reference
(www.tamilnet.com) The latter is in fact, the official website for LTTE
terrorists without any credibility at all. It is possible that there may
have been shortages, as expected in any conflict zones (e.g., Afghanistan,
Palestine, Iraq, etc.). Since the LTTE was the de facto government at
that time in the region she specified, shouldn’t the leadership of the
LTTE be more concerned about the civilians who were made use of to gain
recognition for its existence and took steps for provision of food and
heath care to the poor? According to the priorities spelt by the LTTE
leadership, it is felt that the cyanide capsules were a better option than
proving food for people. Moreover, over the past two decades, Sri Lankan
government continued to ship food and medicine to the conflict zones
through non governmental organizations (NGO)s such as International
Committee for Red Cross (ICRC) etc. (the only government that supplied
food and medicine to the terrorists held areas including terrorists
themselves). Yet, thousands of reports suggest that the vast majority of
food and medicine received in these areas were preferentially utilized by
the LTTE as the distribution was controlled by them
The author states that “Almost 280,000 Tamils people surrendered to
the Sri Lankan military for almost three years”. But, the reality was
that these civilians managed to escape the brutalities and a hostage
taking by the LTTE and the process was facilitated by the Sri Lankan army.
Anna Neistat, senior researcher for Human Rights Watch, told a United
States Senate Foreign Relations committee hearing that human rights
violations are being committed by both sides in Sri Lanka's 25-year-old
conflict. She went on to state that; "The LTTE has deliberately prevented
civilians under its control from fleeing into the government controlled
areas. We have documented several incidents where LTTE forces fired at
fleeing civilians, killing and injuring dozens. We also documented cases
where the LTTE effectively used civilians as human shields to protect
their positions from attack. This is a war crime,"
(http://www.voanews.com/english/archive/2009-02/). The relevant question
to be directed to Dr. Suntharalingam is, who was controlling the North for
the last 3 years and why the leadership of the LTTE did not provide
protection to civilians, and why they used these civilians as human
shields (largest hostage taking in the world) when the terrorists were
facing defeat and death. Even a terrible despot such as Sadam Hussein
never took his own people as human shields. This is the pathetic
terrorist group that my learned colleague is still trying to defend and
the poor people in the North had to escape from the LTTE clutches to
freedom while being upon by their own people..
Author stated that “there is no freedom of movement in Sri Lanka”
which is completely untrue. In fact, over 65% (the majority) of the Tamil
speaking Sri Lankans live happily among the majority Sinhalese and
Muslims, in most of the major cities in the South of the county. Dr.
Suntharalingam concluded by saying “At this juncture I feel helpless and
utterly frustrated for my people”. We too feel sorry for them and that is
not because of the Sri Lankan government’s inaction, but the mayhem caused
by the LTTE terrorists (killing over 125,000 people), and the terrible let
down of these poor people by the LTTE. It is indeed heart rending to
recollect that the Tamil civilians were forced to hand over their children
as child soldiers and some served as suicide bombers (including pregnant
women). During the last stages the LTTE, even took the old parents and
selfishly used them as human shields, rather than fighting the Sri Lanka
army on equal terms.
As for the facilities that are available in rehabilitation centers,
we do agree that there may have been less than optimal. However, the
camps visited recently by many UN and Indian leaders, religious
dignitaries, and also UK and US senior politicians commended the Sri
Lankan government. They all agreed on the fact that the Sri Lanka
Government was doing their best to serve the people, while encouraging
other countries to support them by providing assistance.
Finally, I wish to add a comment to explain the issue from the point
of view of Sri Lanka a sovereign country with a parliamentary system of
Government. Contrary to misconceptions in Dr. Suntharalingam article, the
only group of people in Sri Lanka: are Sri Lankans. There is no
difference among the Tamils, the Muslims, and the Sinhalese in Sri Lanka:
they all have equal rights. One could compare this position with the
British citizenship or the American citizenship, wherein the importances
of the ethnicity, religion, color, or the language they speak become a
nonentity. We who live outside Sri Lanka have very little to advise how
the Tamil ethnic group in Sri Lanka or the Government of Sri Lanka should
solve their problems. Sri Lankan citizens and their elected
representatives are the rightful leaders to manage their affairs.
D.T.Jayaweera MD, MRCOG(UK) FACP, Professor of Medicine. University of
Sunil Wimalawansa, MD, PhD, MBA or DSc , Professor of Medicine, Robert
Wood, Johnson University Hospital.
Competing interests: No competing interests
The nature of the job by health care workers would enable them to
treat patients who are prisoners and injured from battle zones. As a
result of these activities they would be witnessing serious human right
abuses and crimes against humanity. It is their professional duty to
protect the patients who are the innocent victims of such atrocities. It
is their duty to inform the appropriate channels so that the necessary
actions could be initiated to support the victims. Hence the doctors would
be in a difficult position, as sometimes the action could be potentially
very risky and life threatening .The states and relevant organisations
including world medical organisation and United Nation do have a duty to
respect and protect the doctors who are expected to carry out their
professional duties to help the victims. The British medical association
and British medical journal should be congratulated, not only for
highlighting the issues but also working closely with the relevant
organisations to promote the human values (1).
However, it is interesting to see another emerging challenge to the
British medical journal and health care workers. This might be as a result
of politicisation of health care workers in some countries. The medical
doctors and health care workers should do everything to protect their
colleagues and victims. On the contrary the doctors have become the voices
for supporting these elements committing abuses. This led to a situation
where the BMJ was subjected to criticisms and condemnations in the past.
The orchestrated E mail campaign by doctors has been used as an instrument
to suppress or even intimidate the authors highlighting articles against
human right abuses (2). It has been clear how acrimonious responses
bombarded to BMJ whenever any human right issues or crimes against
humanity are highlighted in the journal. It is a new challenge to BMJ to
deal with politicised e mail campaign.
The medical doctors who are in detention were brought to give media
interview by Srilankan authorities (3). These doctors were in the battle
zones treating many thousand injured patients during the war between Tamil
rebels and Srilankan armed forces. While they were commented by some for
their services in the battle zones risking their own lives, they are now
detained by Srilankan government for investigation against allegation of
collaborating with Tamil Rebels. The irony is that they are not allowed to
see any legal representatives or neutral organisations. Some considered
them as important witnesses for war crimes and genocide. Sadly and
humiliatingly, these doctors are brought to the media spot light by the
authorities using them for the political propaganda and to justify their
actions , while they are still in prison. If the doctors are innocent
enough to bring them to the political propaganda, let them walk free. If
their innocence is still to be proved, do not use them for political
propaganda. It is the duty of the medical organisations to stop torturing
the doctors being treated as such.
Further the politics and health are interconnected and inseparable.
Therefore, it is not wise to ignore the issues as political matter for
political expertise. Instead, it is time to re emphasise the importance of
politics, medical law and ethics to medical students and trainee doctor’s
early part of their career. At the same time medical associations and
reputable medical journals should continue to face the new challenges by
politicised doctors undermining the activities of doctors committed for
upholding their professional duty and good will.
1) John Zarocostas, Agencies call for health workers in Gaza to be
respected, BMJ 2009;338:b30
2) Editorials , what to do about orchestrated e mail campaign, BMJ
3) Srilankan doctors recant on
Competing interests: No competing interests
I write with reference to the article entitled ‘Sri Lanka: health as a
weapon of war?’ by Shiamala Suntharalingam, which appeared recently in
your columns. Her article is replete with inaccuracies and misleading
preconceptions, so I would be grateful if you would allow me space to
refute her claims.
In her first paragraph she declares that ‘Throughout the conflict
successive governments have used access to medicines as a weapon of war
against the Tamils who were living outside the military controlled areas
in the Tamil north east of the island’. She is referring here to the areas
that were controlled by the LTTE, which is a terrorist organization banned
in Britain as well as in over twenty other Western countries. The elected
Sri Lankan government in 2002 signed a Ceasefire Agreement which was meant
to ensure negotiations but the Tigers, as the LTTE is commonly known,
withdrew from negotiations in 2003. Instead they used the foolhardy
goodwill of the then government to strengthen their control of the areas
in which, it will be noted, Dr Suntharalingam, doubtless idealistically,
offered her services in 2003.
She would know that in fact medical services in those areas were provided
by the government, which continued to maintain hospitals, pay salaries of
all those who worked in them, and supply medicines and ancillary services
throughout the entire period in which the Tigers physically controlled
those areas. We did the same with education and all other social and other
services. Dr Suntharalingam is therefore wrong when she declares that
‘Since 2006 the Sri Lankan government and its armed forces have
systematically blocked the provision of clean water, shelter, food, and
medicines by civil organisations as well as local and international non-
governmental organisations (NGOs)’. This omits what we provided, but there
was also plenty more as indeed her next sentence proves when she says that
‘In 2008 all international NGOs working in the northern region of Vanni,
including Médecins Sans Frontières, were ordered out.’
That happened in September 2008, more than two years after the doctor’s
cut off date, but that too was because the government could no longer
guarantee their safety following the explosion of a claymore mine which
damaged one of three vehicles of the Norwegian organization FORUT, which
had been delayed several hours at a Tiger checkpoint before being
permitted to proceed after dusk. Fortunately, in a practice we have since
discovered was quite common, the damaged vehicle had only one driver
traveling in it at the time. It is certainly wrong of Dr Suntharalingam to
claim that ‘It became a war without any witnesses’ since the ICRC
continued to operate in the area, while two UN agencies which had been
invited to remain declined to do so themselves, but went in at regular
intervals for six months or so, to convey food and medicine.
Dr Suntharalingam is mistaken when she says that ‘Sri Lankan
authorities denied access to the north east for long term relief and
rehabilitation projects by NGOs’ after the tsunami, as can be seen from
the millions spent in those areas in the last five years. However there is
little to show for these monies, and audited accounts are rarely
available, leading to the inescapable conclusion that those funds, like
many others intended for the Tamil people oppressed and conscripted by the
LTTE were spent on the massive stockpiles of weapons that were discovered
even after several months in which the Tigers used those weapons
ruthlessly, including on those Tamils who tried to flee from them.
It is wrong to say that ‘Almost 280 000 Tamil men, women, and children
surrendered to the Sri Lankan military’ since these people arrived seeking
refuge, having tried for months to flee the LTTE but being prevented from
doing so, as they have testified again and again to the visitors who have
spoken to them. Even advocacy groups with no sympathy for the government,
such as the Jaffna University Teachers for Human Rights, acknowledge that
the Tigers brutally held these people as hostages for months, driving them
into ever shrinking spaces to use them as and when needed. When the good
doctor declares that ‘The officials refer to these people as internally
displaced persons (IDPs).’, she reveals her hand, because that is what the
world calls them, whereas terrorist sympathizers, who evidently wish to
revive the LTTE, believe they are citizens of a mythical Eelam..
She is right in saying that those who have not yet been security cleared
are not allowed to leave, but they are certainly permitted to communicate
with the outside world, not only with the over 50 external agencies
operating in the camps but also with journalists and other visitors, as
well as through telephonic communication (which is how the British health
worker, erroneously described in despatches from the front as a doctor,
informed her family who finally stirred the British High Commission into
action on her behalf).
Schools are operating in the camps and IDP teachers are employed in them.
This was intended from the start, though structures have been slow to get
off the ground because of the vast numbers that came in and also because
UNICEF, which undertook the responsibility, was slower in setting up areas
for schools than we had anticipated. She is quite wrong about claiming
that the ‘official pronouncement is that these people will be kept under
these conditions for the next three years or so’ since the government
plans to resettle them as soon as possible, 80% during this year, though
of course removing the mines the LTTE laid will take time and that
exercise may not be fully completed for a couple of years.
Thankfully the doctor notes her source for the most shaky of her claims,
in saying that ‘Women have been separated from their families and sexually
abused, according to Britain’s Channel 4’. The Ministry of Disaster
Management and Human Rights, of which I am the Secretary, is in charge of
Protection, and we work on this with the UN and several NGOs. None have
suggested any rationale for the Channel 4 story, which was telecast
without any attempt to ask for government comment. Certainly people had
been separated from their families in many instances by the time they came
into the camps, but government is reunifying them, and has succeeded in
doing so with several thousands already. With regard to sexual abuse, the
incidents relate to problems amongst IDPs, which have been brought to our
attention, along with suggestions for preventive action which has been
taken. Dr Suntharalingam may claim that this is all she meant to convey, but her source seemed to be trying to
suggest that Sri Lankan servicemen were responsible. That there has been
no trace of this was certified by all protection partners.
The doctor is again mistaken in claiming that Tamil doctors were
refused access to the area, though she may indeed have heard such a thing
from her sources. The fact is that, for many years, Tamil speaking doctors
who were appointed to these areas were unwilling to serve, and indeed they
were at greater risk from the Tigers than their colleagues in government
service, since they were branded as traitors if they did not give full
allegiance to the LTTE. The government has continued to post several
doctors to the area, and in particular those who speak Tamil, while others
work on a voluntary basis on programmes organized by several NGOs. Though
obviously there is a massive need for medical services, these have been
generally satisfactory, and none of the epidemics predicted with such glee
by the Tigers and their supporters have occurred.
The UN Secretary General was in fact referring, through the word
‘appalling’ not to the camps but to
the area in which the Tigers held thousands of hostages to fight their
last battle. The UN acknowledges that access has improved, after being
subjected to security safeguards following a couple of instances of abuse.
Meanwhile MSF assure me that the quote the doctor uses from Severine
Ramon, coordinator for Médecins Sans Frontières, was taken out of context,
a common practice in those who wish to denigrate Sri Lanka but wish to
throw the burden of this on others. It should be noted that such
techniques are sometimes successful in adversely affecting relations
between government and NGOs, to the delight of characters such as Dr
Suntharalingam who evidently wants her critique to prove true at some
stage in the ideal future she imagines, in which only the murderous Tigers
are left in charge of these poor civilians.
It should be noted too that the government doctors to whom she refers are
of course being questioned, as for instance the British did with P G
Wodehouse after the Second World War, in which he had been forced to say
things to satisfy his Nazi captors. Whilst there is obvious need to check
on whether they should be prosecuted for providing material used by a
murderous enemy, we can hope that the defence used in the case of
Wodehouse, that pressures had been applied to which it would be
unreasonable to expect resistance, will be found applicable, and they can
return to their generally admirable work.
Finally, Dr Suntharalingam obviously doesn't know that
government has been working with the ILO on a framework for the
rehabilitation of those she describes as LTTE fighters, which includes
several who were forcibly conscripted. The IDPs have told us horrific
stories of how they strove to keep their children hidden to prevent
conscription, a practice in which sadly several NGOs connived, only
raising objections (and indeed attempting to justify this pusillanimity)
when the children of their employees were being rounded up. Dr
Suntharalingam is certainly welcome to contribute to the fund for
rehabilitation, and I hope she will choose to do this, instead of
encouraging the rump of the LTTE that still functions in several European
countries, and most prominently in Britain, to continue to stockpile
weapons in its effort to sacrifice yet another generation of the poor
amongst the Tamils for their dream of a puppet state they can control from
Prof Rajiva Wijesinha
Competing interests: No competing interests
I wish to thank both the BMJ and Dr. Shiamala Suntharalingam for the
article titled ‘Sri Lanka: Health as a weapon of war?’. Dr. Suntharalingam
provided an accurate first hand account of the discrimination faced by the
Tamil people at the hands of successive Sri Lankan governments. It is the
responsibility of doctors to speak up for the voiceless and the oppressed
Dr. Suntharalingam did this very well.
Speaking from experience, I worked in the North-East, during the period of
cease-fire and witnessed the discrimination of the Sri Lankan government
first hand. Ultrasound and CT machines, donated by the international
community, were held at the Colombo docks for months to rust and become
dysfunctional before being transported to the North-East. Furthermore,
equipment sent to Colombo for repair were returned, untouched. This forced
us to work in an extremely challenging environment, with minimal or no
functioning equipment. I participated in operations, including limb
amputations, without the use of anaesthetic and adequate monitoring
equipment. Drugs, including analgesics and antibiotics, were expired. As a
result many of our patients did not survive even the most basic pathology.
How this can be allowed to happen in the 21st century is something I will
never understand. Furthermore, my paternal grandfather starved to death in
Jaffna in 1999, due a government embargo on food and medicines.
On August 4, 2006 17 Tamil aid workers, working for the charity, Action
Contre La Faim (ACF) were murdered in an execution-style killing.
Government backed forces were strongly suspected to be the perpetrators of
this crime. The charity ceased operations in Sri Lanka two years later
frustration at a lack of an open, substantive inquiry into the killings.
own representative was denied permission to attend the hearings.
Furthermore, an investigation conducted by Sri Lankan ‘experts’ was not
consistent with an Australian forensic report and subsequent ballistic
examinations were conducted without the presence of an international
observer. (1,2). All these clearly illustrates the Sri Lankan government’s
attempts to cover-up its role in the killings.
In 2007, Mr. John Holmes, the United Nations Undersecretary General for
Humanitarian Affairs, stated that Sri Lanka was one of the most dangerous
countries in the world for aid workers. The Sri Lankan government
subsequently labelled him a ‘terrorist’ (3).
In November 2007, more than 100 Sri Lankan troops, serving with the U.N.
peacekeeping mission to Haiti, were sent home in disgrace after sexual
of the local women, including minors. This too, has never been properly
These incidents put into context, the Sri Lankan government’s views on
provision of aid, and treatment of aid workers and civilians by the
During the recent escalation of hostilities, the Sri Lankan military
civilian infrastructure, including hospitals, houses, places of worship,
and orphanages. The Sri Lankan Defence Minister, Gotabaya Rajapaksa, is
quoted as saying that anything outside the safety zone, including
was a legitimate target for shelling, directly contravening the Geneva
Convention (5). In addition, the safety zones were themselves targeted
incessant artillery shelling, with the loss of thousands of innocent
International non-governmental organisations were forced to leave the
conflict zone, ensuring that there was an absolute lack of food and
and no neutral bodies were present to act as witnesses to the human rights
abuses and killings. There are now moves to bring both Gotabaya Rajapaksa
and Sarath Fonseka, the head of the military, to justice in America (6).
As has been stated, since the end of the bombardment by the Sri Lankan
military, 300000 Tamil civilians have been languishing in detention camps,
where they have been subject to gross lack of food and medicines,
tremendous overcrowding, abductions, including the abduction of children,
rape and torture, at the hands of government officials (7, 8, 9, 10).
A ship, from Britain, carrying 900 metric tonnes of food and medical aid
the displaced, was intercepted by the Sri Lankan navy and not allowed to
unload its cargo (11). This was clearly designed to punish its most
Six weeks after the end of the shelling, international NGOs and media have
not been allowed into either the conflict zone or the detention camps.
aid workers remaining in Sri Lanka have been forced to leave the country,
the government continues to cover-up ongoing human rights abuses (12).
The Human Rights Leadership Coalition, consisting of Amnesty
Physicians For Human Rights, The Carter Centre, Freedom House,
International League for Human Rights and Jacob Blaustein Institute for
Advancement of Human Rights, have recently written a letter to President
Obama requesting that he intervene in the deteriorating human rights
situation in the internment camps (13). This demonstrates the level of
international concern for the trapped Tamil civilians, and the lack of
confidence in the Sri Lankan government.
In addition, Physicians for Human Rights have also demonstrated support
the three detained Tamil doctors (14), who bravely treated the injured and
dying in the safety zone, as shells landed around them. These doctors also
served as the sole source of information regarding the level of carnage
inflicted by the Sri Lankan military, much to the ire of the Sri Lankan
I agree with Dr. Somasundaram that responses have been divided along
ethnic lines. However, what is happening in Sri Lanka is primarily a human
rights issue. As in Zimbabwe, the issue is one of successive governments
persecuting a minority group, using food and medicine, our most basic
needs, as one of its many weapons.
1. The Muthur Massacre: ACF Questions the Facts
2. Muthur Massacre: ACF Denounces Ineffective Legal Procedures in Sri
Lanka (Reuters News).
3. Top Sri Lanka official calls U.N. aid chief “terrorist” (Reuters News).
4. S Lanka troops ‘abused Haitians’ (BBC News).
5. Sky News: Sri Lankan Defence Secretary Gotabaya Rajapaksa tells SkyTV.
6. Fonseka, Gotabaya Genocide charges filed with US Justice Dept.
7. Tamil refugees forced into sex rackets
8. Children 'being kidnapped from Sri Lanka refugee camps'
9. S Lanka camp young malnourished' (http://news.bbc.co.uk/go/em/fr/-
10. Tamil refugees may end up in permanent camps, say aid workers
11. Sri Lanka navy seizes British Tamil aid ship on 'mercy
12. Aid staff expelled over 'Tiger links'
14. Sri Lankan Physicians Detained for Adhering to Medical Ethics.
Competing interests: No competing interests
Despite our best efforts, we continue to be plagued with prejudice in all its ugly
manifestations. Why is prejudice so resistant to all intervention? Perhaps there
is a biological component that we are overlooking. Perhaps prejudice is similar
to an immune response, in which we automatically recognize and reject foreign
protein as potentially dangerous.
Our immune response is a mixed blessing, because sometimes the foreign
protein is dangerous, but other times the foreign protein is harmless.
Sometimes our immune response protects us, but other times our immune
response turns on us and creates self-destructive autoimmune diseases such
as rheumatoid arthritis, rheumatic heart disease, multiple sclerosis,
scleroderma, lupus, and colitis.
I propose that prejudice is a self-destructive autoimmune disease, in which we
automatically and incorrectly reject harmless people who appear to be foreign
and dangerous. Let's treat the pernicious disease of prejudice with familiarity,
tolerance, reason, good will, and hope.
Competing interests: No competing interests
I am a 2nd generation Tamil with roots in the island of Sri Lanka.
But I am also medical student in the United States. As a student, I have
come to understand some implicit assumptions about the role of medical
humanitarianism around the world:
1) Physicians have an unviolable right to access the sick, no matter
when or where.
2) Individuals have an unviolable right to food, water, and life-
saving medications, regardless of ethnicity.
3) Hospitals are never legitimate targets in war.
4) NGOs can be expected to fill gaps in medical care when governments
Shockingly, each of these assumptions has been struck down by the
Government of Sri Lanka. My simple question is: why? If the problem was
simply one of "terrorism", why limit health care access for hundreds of
thousands of Tamil civilians? Why create a situation in which newborns die
for lack of milk powder? Why bomb hospitals repeatedly and then claim they
are "legitimate targets"? Why eject nearly all NGOs in anticipation of a
major military offensive?
I ask that those who find fault in Dr. Suntharalingam's article
please answer these questions, for they lie at the heart of the
desperation which I'm sure compelled her to write. Even now, Tamil
children in military detention camps are dying of Varicella and Hepatitis
and Encephalitis... and I am reading about this horrible news as I learn
about those very infectious diseases in school.
Please, will the defenders of the Sri Lankan government please
answer my questions? Those answers will set a precedent for the
relationship between health and war in the decades to come.
Competing interests: No competing interests
Going by the acrimonious responses to Dr. Suntharalingam’s
viewpoint, it is easy to understand why the conflict in
Lanka was called an ethnic, civil war and the bmj.com has
become a virtual battlefield. Suntharalingam’s original
missive and the responses neatly divide along polarized
ethnic lines, clearly representing the ethnic group, Tamil
or Sinhala, that they belong to. As some of the responders
point out, one sees what one wants to or believes and as
brought out, the only way ‘health can be used as a bridge to
peace’ would be to transcend these boundaries and adopt our
health professional roles. However, for emotional reasons
this is not possible and this is the fundamental problem in
What the predominantly Sinhala respondents, while
berating the BMJ for publishing a biased report, fail to do
is acknowledge the equal if not morally higher culpability
of the Sinhala state and power structures in the quagmire
that has been created and continues to be maintained. As a
person who has worked in the North of Lanka for more than
the past two decades from before and amidst the war, I
documented the inequities and negligence in the health
sector in a report  prepared at the request of the Human
Rights Commission of Sri Lanka when Dr. Radhika Coomaraswamy
the current UN Special Representative for Children and Armed
Conflict, was the chairperson that Dr. Suntheralingam is
describing in an emotive way. One needs to only just walk
into one of the hospitals in the north, for example the
Jaffna Hospital, and compare it to an equivalent district or
tertiary hospital in the south to see the difference in
resources, staff and facilities. Though the LTTE has been
responsible for much of the abuses of the health sector as
brought out in the report, one must not forget the fascist
LTTE was a historical and contextual creation and a response
to the Sinhala state machine and a mirror image of it .
The easiest way to have prevented its creation and then
defeated it would have been to address the many minority
inequities and grievances which the state was and is
emotionally unable to do. This can be clearly discerned in
the way the national problem and the 300,000 IDP’s continue
to be handled. If one goes through the responders
representing various leading health bodies, colleges,
departments, ministries, not to mention other state
structures, it can be appreciated that the minorities,
particularly Tamils have been excluded from positions of
power or responsibility. Why not allow neutral civil
authorities to deal with the 300,000 IDP’s or run the north
and east? When there are polarized accusations and counter
responses of such serious import, why not allow in impartial
investigators to determine what happened in the last phase
of the war? Were there war crimes committed by both sides?
It would appear that the IDP’s and the three Tamil doctors
in particular are being detained and subject to immense
psychological pressure just because they were credible
witnesses to what happened and as a collective punishment
for being associated with the LTTE. The Tamil doctors were
doing a arduous task in a complex political emergency. It
is accepted practice that in situations of contested
power  ordinary workers have to serve several masters if
they are to survive and help civilians. This was the case
from the senior most government administer to the lowest
clerk and casual labourer. Having worked in these
circumstances and considered a persona non grata by all
sides due to my critical and pacifist writings  , I can
attest that there are no alternatives to working in the best
interests of the patients and community other than fleeing
and avoiding the ethical and moral dilemmas involved.
have worked with the LTTE, training their Tamil Eelam Health
Service personnel, going where they gave me access and
collaborated with their structures to provide health care.
At the same time, I worked with the state health structures,
attended their meetings in Colombo, was a member of numerous
committees and bodies and was paid by them though the state
was responsible for grave human right abuses, abductions,
extrajudicial killings and torture [6, 7]. International
NGO’s like the ICRC, MSF and UN organizations as well as
local governmental and NGO’s were and are doing that. Dr.
Sathiyamoorthy was no exception. Having worked closely with
him, I can attest that he was one of the finest human
beings, utterly dedicated, authentic and humble, working
tirelessly to find the best way of providing meagre services
with the limited resources available. I have known him to
work long hours, travelling all over the district and
outside to make arrangements and find ways to provide health
care under the most risky and difficult conditions. His
reports from the warfront hospital were accurate and
professional , trying to prevent the casualties and
deaths that any preventive doctor would try to do under the
circumstances. His only shortcoming was the omission of
reporting what the LTTE was doing, their abuses and the
casualties they were causing. Working within the LTTE held
areas, he could not have reported on them. It is the same
situation in Colombo, nobody can accurately report on what
the Lankan security forces is doing and stay alive. Instead
of honouring his selfless and courageous work, he is being
detained and punished.
1. Somasundaram D. Health and human rights in the
Jaffna peninsula. Colombo: Human Rights Commission of Sri
Lanka, Regional Committee in Jaffna; 2005
2. Hoole R. Sri Lanka: The arrogance of power, myths,
decadence, and murder. Colombo: University Teachers for
Human Rights (Jaffna); 2001
3. Somasundaram D. Parallel governements- living
between terror and counter terror in Jaffna (1982-2006). In:
Roberts M, editor. Globalizing Religions and Cultures; 1-5
December 2008; Adelaide: University of Adelaide; 2008
4. Somasundaram D. Child soldiers - understanding the
context. BMJ 2002;324(7348):1268 - 71.
5. Somasundaram D. Abandoning Jaffna hospital-ethical
and moral dilemmas. Medicine Conflict & Survival 1997;13:333
6. Human Rights Watch. Recurring nightmare state
responsibility for “disappearances” and abductions in Sri
Lanka. New York: Human Rights Watch2008 Contract No.: 2 (C).
7. Somasundaram D. Psycho-social aspects of torture in
Sri Lanka. International Journal of Culture and Mental
8. University Teachers for Human Rights- Jaffna. A
marred victory and a defeat pregnant with foreboding.
Colombo: University Teachers for Human Rights (Jaffna)2009
10th June 2009 Special Report No.: 32.
Tamil doctor working in
Competing interests: No competing interests
The mind perceives what it agrees with. It filters reality according
to its values, prejudices, feelings, attitudes, interests, goals and
agendas and producers a perception.
Dr Shiamala Sunderalingam in her letter to the BMJ perceives the
Government of Sri Lanka as using health as a weapon of war. We who have
worked in the IDP camps in Northern Sri Lanka perceive the efforts that
are being made as a road to achieving Peace through Health.
Yes, these Tamil people are physically and psychologically
traumatized, but so are numerous Sinhalese in border villages who faced
ruthless attacks by the LTTE, and the families of those who lost loved
ones in train bombs, bus bombs, attacks on public buildings and other LTTE
atrocities – the list is long.
The IDPs are in such a sorry state because they were being held
hostage by the LTTE. The food that was meant for these people was hijacked
by the LTTE, they including children were used as fire fodder and slaves
to build earth bunds etc. They did not surrender to the government forces,
they were rescued by them.
True those camps are overcrowded, but every person has a roof above
their head which is more than the situation among the IDPs of the SWAT
valley in Pakistan. It is not the ideal way for traumatized persons to
live, but the Sri Lankan government and the people in the South are doing
their very best. E.g. no foreign media has ever commented on the tons of
food, items of clothing, other necessities and funds that have been
collected in the South for the IDPs.
There is no ban on Tamil doctors working among the IDPs. Quite
contrary to Dr. Sunderalingam’s claim, there are many examples of health
professionals from different ethnic communities working together. The Sri
Lankan situation can actually be considered as a golden opportunity to
promote the more positive concept of “health as a bridge for peace” as
opposed to Dr. Sunderalingam’s destructive and biased concept of “health
as a weapon of war”.
Dr. Indika Karunathilake
Director, Medical Education Development And Research Centre,
Faculty of Medicine,
University of Colombo,
(This writer was the team leader of a medical team that recently
worked among the IDPs. at the Ramanthan relief village, Chettikulam. This
team comprised of academic staff, junior doctors and medical students.
There were four Muslim doctors and five Tamil doctors in the team)
Competing interests: No competing interests
VIEWS & REVIEWS
A response from The Sri Lanka College of Paediatricians to “Sri
Lanka: health as a weapon of war ?”
The Sri Lanka College of Paediatricians
(http://www.srilankacollegeofpaediatricians.com/index.php) wishes to
respond to the above named article, which appeared in the BMJ of 13th June
Unfortunately the author of the article has provided ‘misinformation
as a weapon of war’ to the readership which often happens in conflict
situations as adverse false propaganda is a weapon used by most terrorist
The said article makes various unfounded allegations against the
democratically elected government of The Democratic Socialist Republic of
Sri Lanka. The carnage created and carried out by the world famous and
utterly ruthless terrorist organisation known as The Liberation Tigers of
Tamil Eelam (LTTE) over a three decade long armed conflict in Sri Lanka is
only too well known to the international world. This organisation is
currently banned in most Western Countries including US, UK, EU and Canada
These so-called “freedom fighters” not only killed and maimed tens of
thousands of Sri Lankans in the South of the country but also perpetrated
numerous atrocities against the Tamil people in the North and East of the
country http://canadiancoalition.com/LTTE/Massacres.html . During their
last days, they even shot, killed and maimed, not only their so-called
“own people” but children as well, who attempted to escape from the human
shield and seek refuge in the safety of the government authorities.
The author states that the Sri Lankan government and its armed forces
have systematically blocked the provision of clean water, shelter, food,
and medicines. There is no truth whatsoever in the statement that the
government of Sri Lanka ever used health as a weapon of war at any time
against the unfortunate people of the North and the East of the country.
For the last 30 years of the conflict, the people in the affected areas
including the terrorists were fed by the government and the UN/WFP and
medicines supplied by the government of Sri Lanka through the ICRC.
It is on record how the LTTE plundered these supplies to their own
advantage on numerous occasions and deprived the populace of the region
the benefits of health care.
The Hospitals were supplied and managed by government doctors who
were paid by government. The ICRC also was also involved in the process.
was the LTTE that restarted the war in 2006 during the ceasefire when the
main Mavil Aru annicut sluice gates were forcibly closed by the LTTE. This
activity deprived about 60,000 people and 30,000 ripe paddy land for
irrigation. Col R Hariharan (retd.), South Asia Analysis Group SRI LANKA:
MAVIL ARU OPERATION & AFTER - An Analysis.
The author also states “the Sri Lankan authorities denied access to
the north east for long term relief and rehabilitation projects” during
the Tsunami, which is also untrue, since the then Sri Lankan President
Chandrika Kumaratunga's bold decision to push through a deal to share
international tsunami aid has restored hopes of a negotiated settlement to
the island's ethnic conflict”. Instead the LTTE robbed the Tamil people
who received funds after the Tsunami. Asia Tribune:
The statement in the article that the government prevented foreign
donors from meeting the LTTE is also false since “The LTTE chief, V.
Prabhakaran raised the issue of direct aid with the Norwegian Foreign
Minister, Jan Peterson, who called on him in his Killinochchi headquarters
on January 28.” India News Online:
Even the LTTE terrorists website mentions “Mr Akashi (the Japanese special
envoy) met the LTTE delegation at the Kilinochchi LTTE Peace
Secretariat..” which contradicts the author’s statement.
The author mentions several statements that are hearsay
undocumented statements that amount to propaganda such as “According to
local NGOs, the sick are allowed to seek limited medical help...” and “I
have heard from colleagues in the area that Tamil doctors from other
regions of Sri Lanka who came forward to serve these people have been
refused access. The readers of a prestigious Journal would expect evidence
based information. The Sri Lanka College of Paediatricians has arranged
for a roster of specialists to work in these areas including Tamil
doctors. Of course, we asked all members of the College and some
Tamil doctors responded while some refused for personal reasons. So far,
many Tamil doctors have and are still working in the IDP camps.
It is on record, quite contrary to the impressions generated by the
article in the BMJ, how countless numbers of Tamil doctors refused to
serve in these areas over the last three decades. In those circumstances,
many Sri Lankan doctors from the South did go and work selflessly in those
areas, leaving their families and relatives behind in the South of the
country. The Sri Lanka College of Paediatricians is proud to record that
many young and even experienced paediatricians did go and work in these
areas over the last three decades. They did their best even under those
appalling conditions created by the LTTE.
Admittedly, there are quite significant problems in the camps of the
Internally Displaced Persons (IDPs) at the present time. The government of
Sri Lanka in general and The Sri Lanka College of Paediatricians in
particular, have taken steps to provide medical assistance and from our
point of view, paediatric care, to these, our very own people, of our own
country. As befits a renowned academic organisation, The Sri Lanka College
of Paediatricians, looks at these children just as children and quite
unlike the LTTE, not as Tamils or children of any other community. For us,
children are the same, wherever they come from. Teams of paediatricians
and other doctors have been visiting these camps, for days on end, at
great personal sacrifice, to try and provide the best possible care for
these children. Some of the more recently trained paediatricians have even
elected to serve on a long-term basis in the hospitals of these areas. We
are doing our best to try to cope with a situation that was originally
created by the LTTE itself. The government of Sri Lanka is determined to
sort out the problems of these IDPs as fast as is humanly possible and re-
settle them back in their own homes within a period of six months or so.
It is most unfortunate that, such biased and adverse articles as the
one referred to, do create a completely erroneous impression of the goings
-on in our country. Many of the professionals of Tamil origin, who have
elected to desert their motherland in its gravest hour of need, under the
guise of “asylum seekers” and “refugees”, to secure a beneficial haven in
the Western world, have now started a campaign of misinformation and
journalistic terror to discredit the government and professional
organisations of Sri Lanka. It is worthy of note that even the Tamil
doctors, listed by name in the article, have now explained to the
authorities how they were forced and coerced by the LTTE to provide
erroneous and damaging information to the international media. They had no
alternative but to accede to these coercions as they literally had several
guns pointed at their heads during those intensely stressful encounters.
We are sure that the government is quite cognizant of the facts of these
cases and will be sympathetic to their plight. There is no reason
whatsoever to doubt their safety.
Hopefully, the terrible war of the last three decades is over in Sri
Lanka. It had taken a dreadful toll of the people of our country. We need
to regroup and rise like the proverbial phoenix, from the ashes. The need
of the hour in Sri Lanka is not to mull over the past, shed crocodile
tears about the plight of some sections of Sri Lankans, but to take steps
to help all Sri Lankans to live in peace and harmony right throughout our
beautiful country. As our own President of the country eloquently extolled
recently, we should not think of our own people by any sort of segregation
of ethnicity, culture, creed or religion. He said categorically that there
are only two types of Sri Lankans, one which loves and feels for the
country and the other, quite the opposite. It is blatantly obvious to
which of these groups, the members of the Tamil diaspora that disseminate
misinformation belong to.
Dr. H.T Wickramasinghe
On behalf of the Council of Sri Lanka College of Paediatricians.
This article seems to be written to mislead readers by providing misinformation and unfounded allegations against a democratically elected government of a country.
Competing interests: No competing interests